The Diet Structure and Body Mass Index Among Polish Preschool Children in Relation To Their Place of Residence

Abstract Introduction and aim Proper nutritional status in early childhood makes it possible for children to achieve their genetically-determined growth potential and intelligence. A child’s nutritional status is due to economic, cultural, psychosocial and geographic factors. The present study aims to check whether the nutritional status of preschoolers differs depending on their place of residence. Materials and methods In order to achieve this goal we used 24-h dietary recalls to assess the children’s diet based on interviews with 530 mothers of preschool children from five different regions of Poland. Moreover, the children’s BMIs were calculated. Results We found differences in the level of anthropometric indicators, diet structure and what percentage of the estimated average requirement for energy was met depending on the region where the children live. Youngsters from the western region of Poland had significantly higher BMIs than those from other regions. What is more, the percentage of meeting the estimated average requirement for energy and the percentage of calories from carbohydrates was higher among children from the western region, as compared with preschoolers from other areas of the country. The amount of fats and protein in the diet of children from western Poland, in turn, was significantly lower as compared with the diet of their peers from other regions. Conclusions The present study provides evidence that the nutritional status of children should be analyzed in the context of their place of residence. Thus, the differences between regions and their impact on the health status of their inhabitants should be taken into account when designing preventive or corrective measures.

Słowa kluczowe: stan odżywienia, dieta, przedszkolaki, czynniki geogra czne, region zamieszkania INTRODUCTION Childhood obesity already a ects more than one in four school-age children in Europe and in many countries the prevalence is increasing [1]. e number of young children (aged 5 or less) with excessive weight is also rapidly growing [2]. e problem of malnutrition also refers to Poland − 1/3 of all school-age children su er from overweight or obesity [3]. Yet, even though previous studies suggest that malnutrition occurs in Polish children of all age groups, it is hard to estimate the exact scale of the problem in younger children (preschoolers), since research on the nutritional status involving this age group is particularly scarce in Poland [4]. e nutritional status of children might di er depending on their place of residence, as revealed by some research ndings [5][6][7]. e di erences in the nutritional status of children living in various regions of Poland, as well as di erent places in other countries, might be due to socioeconomic (poorer versus wealthier regions) and cultural factors (eating habits and traditions, regional cuisine). Some authors argue that programs addressing childhood obesity that consider the role of the particular region' s speci city are more e ective [8][9][10][11]. e di erences in people's attitudes and habits make some preventive and corrective actions more or less e cient [8]. For instance, in France the promotion of healthy eating proved more e ective when the focus of communication was shi ed onto the pleasure related to healthy eating and working out, without focusing only on the health bene ts themselves [12].
To prevent malnutrition also among Polish children, it is necessary to conduct more research in this eld, especially to run studies on preschoolers including their place of residence as a potential factor. us, in the present study we aimed to check whether the indices of nutritional status vary between the children living in di erent areas of the country. To the best of our knowledge, this is the rst study including a national sample of Polish mothers that investigates the place of residence as a factor di erentiating the preschoolers' nutritional status. e present study constitutes part of a larger research project on the sociodemographic determinants and the role of the mother in the development of malnutrition in preschool children. e publication was prepared within the framework of a statutory project of the Nofer Institute of Occupational Medicine (IMP 21.3).

MATERIAL AND METHODS
Procedure and parƟcipants e study sample included 530 mothers of preschool children from ve regions of Poland -the central, western, eastern, northern and southern one, each represented by one voivodeship. e central region was represented by the Masovian Voivodeship, the western one by the Lubusz Voivodeship, the eastern region by the Lublin Voivodeship, the northern one by the Pomeranian Voivodeship and the southern region by the Silesian Voivodeship. Two pediatric clinics were randomly selected from each region -one located in an urban and the other in a rural municipality. From these randomly selected institutions we recruited mothers who had at least one child aged 3-5 years. To avoid the confounding e ect of any third parties engaged in the child's diet, we excluded mothers who self-assessed their control over the child's diet as lower than 70% and those whose children were being taken care of by babysitters (>2 hours a day) or grandparents living in the same household. e statistical analyses were performed on a sample of 400 women − 80 respondents from each region (40 from urban and 40 from rural areas). e mothers were on average 30.4 years old (+/-4.4). Women with secondary (N=172) and bachelor-degree education (N=93) dominated in the sample (43% and 24%, respectively). Vocational education was declared by 19% (N=74) of the respondents, a Master's degree by 13% (N=51) and primary education by 3% (N=10) of the women.

Measures
To gather the data, trained interviewers conducted face-to-face, structured interviews with the mothers. e questionnaires included: -the socio-demographic characteristics of the mothers and children − place of residence (region of Poland), age, personal and occupational status -the child's nutritional status: on the data declared by the mothers; and type of food consumed by the child during the day preceding the study based on a 24h-dietary recall lled in by the mother. Standard portion sizes were estimated using the food photographs album deve-loped by the National Food and Nutrition Institute [14]. Based on this information, we calculated: the percentage of meeting the estimated average requirement for energy (EAR %) and the percentage of energy in the child's diet coming from carbohydrates (EC %), fat (EF %) and proteins (EP %).

StaƟsƟcal analysis
To assess the diet structure, Dieta5 so ware was used [15]. We used one-way ANOVA to compare the indices of the children' s nutritional status and diet structure. All the statistical analyses were performed using STATISTICA 10.

RESULTS
e ANOVA results showed signi cant di erences as regards all the analyzed indices of nutritional status (BMI, EAR %, EC %, EF % as well as EP %) among children from di erent regions of Poland (Table I).
Post hoc analyses (the Bonferroni test) revealed that children from western Poland achieved signi cantly higher scores as regards BMI than children from all the other regions ( Figure 1). Also %EAR ( Figure 2) among children from the western region was signi cantly higher than that of children from northern and eastern Poland (the Bonferroni post hoc test signi cant at p < 0.01 in both cases). Additionally, children from the eastern and southern regions di ered as regards their %EAR (the Bonferroni post hoc test signi cant at p<0.01).Similarly, %EC ( Figure 3) in children from the western regions was also signi cantly higher and %EF signi cantly lower ( Figure 4) than those of children from the other regions of Poland (the Bonferroni post hoc test signi cant at p<0.05 in all cases). Also %EP among children from western

/%EB w diecie dziecka P ó ł n o c n y C e n t r a l n y Z a c h o d n i W s c h o d n i P o ł u d n i o w y
e diet structure and body mass index among Polish preschool children in relation to their place of residence Poland was signi cantly lower than that of children from the central, eastern and southern region of the country (the Bonferroni testp < 0.05) ( Figure 5).

DISCUSSION
e results showed signi cant di erences in the nutritional status of children depending on their place of residence. Such ndings con rm that the place of residence in uences the di erences in the foods consumed and thus the nutritional status of the person [5,[16][17][18].
Our results also showed that the structure of the children's diet was di erent in western Poland, as compared to other regions. e level of meeting the norm for energy intake (%EAR) was higher among children from the west as compared to children from other regions. Moreover, the percentage of energy coming from carbohydrates (%EC) in the diet of children from the west (60.6%) was higher than that of children from other regions and exceeded the recommended level of 50-55% [19]. Hence, it is probable that higher BMI values among children from the western region resulted from high %EAR and the excessive intake of carbohydrates. Further, the percentage of energy coming from other sources − fat and proteins − was signi cantly lower in the diet of children from the western region in comparison to other children.
Our results revealed that the indices of the nutritional status of children from western Poland turned out to be highly distinctive in comparison to children from other regions. First, the variance analysis revealed that the average BMIs of children living in the west were signi cantly higher than those of children from the other regions. Such a result implies that children from western Poland are at a higher risk of overfeeding disorders in comparison to other children. To some extent, such results correspond to those of the National Food and Nutrition Institute [5] which showed that excessive body mass among 9-year-olds was most common among children from central and western Poland, and least common in the south. Moreover, a Polish nationwide study revealed di erences in the basic anthropological parameters between children from various regions of the country [6]. e children and teenagers who were studied (aged 7-18) and came from eastern Poland had lower height and weight in comparison to the respondents from other regions. Similarly, our results showed that children from the east achieved the second lowest BMIs in the sample (the lowest were observed among children from the south). Nevertheless, the studies by the National Food and Nutrition Institute [5], as well as by Kułaga and colleagues, [6] involved older children than those in our sample, thus the possibility for comparison is somewhat limited.
In general, we observed the most contrasting results as regards the diet structure between the children from the western and eastern regions of Poland. e children from the west had a higher total calorie intake, their diets were higher in carbohydrates and lower in fat and proteins in comparison to the children from the east. Hence, the comparison of these two regions points to the conclusion that the children from the west ate a carbohydrate diet, whereas the diet of children from the east was higher in proteins and fats. Such discrepancies could be hypothetically interpreted as a result of the di erences in regional cuisines. However, the everyday diet in eastern Poland is richer in carbohydrates (high consumption of pierogi -dumplings, porridge and potato dishes, typical of Kresy -i.e. the Eastern Borderlands) than in proteins (meat is considered more as a side, rather than a main dish) [20]. e diet in the western region, in turn, is more eclectic, combining dishes characteristic for the Eastern Borderlands, Greater Poland, Germany and many others. erefore, there should be no considerable di erences between the ordinary cooking in these two regions. Moreover, it can be assumed that economic factors can in uence the typical food consumption. Lowincome families eat more foods rich in carbohydrates, such as bread, potatoes and sugar, whereas high-income families are reported to consume more beef, sh, cheese and yoghurts, i.e. products high in proteins [21]. Data on the nancial situation of Polish households for 2012 demonstrate that in the Lublin Voivodeship (eastern Poland) 35% of the families were classi ed as the lowest-income group, whereas in the Lubusz Voivodeship (western Poland) there were only 21% of such families. ere were no clear di erences between these regions as regards the number of households classi ed as having the highest income [22]. Hence, it could be assumed that the diet of children from the eastern region would be richer in carbohydrates, rather than in proteins, yet our results showed the opposite results. erefore, we must consider the possibility that these di erences are not due to the local, regional cooking or economic factors and it is not these that have a major impact on the nutritional status of children but the people's eating habits, such as snacking or adding sugar to beverages. It is probable that children from the western regions eat more sweets or white sugar, hence the higher consumption of carbohydrates and BMI. e relationship between weight excess and an improper diet structure has already been investigated by Goluch-Koniuszy and colleagues [23] who assessed the diet of 13year-olds living in northwestern Poland. e authors found that overweight and obesity in children could be caused by excessive consumption of simple sugar coming from sweets, sweet baked products, sweetened so and energy drinks. Our results, along with those by Goluch-Koniuszy and colleagues [23], indicate the need for comprehensive eating assessment including an in-depth qualitative analysis focused not only on the amount of the food consumed, but mainly on the kind of foods eaten by children. Such an assessment should also involve the analysis of eating habits, which are shaped by social (culture, eating habits and traditions prevalent in the given region), as well as individual factors (attitudes, eating preferences, mental status, succumbing to external in uence). Only a detailed and comprehensive analysis of local, regional, countryspeci c factors along with individual ones makes it possible to develop e ective preventive programs addressed to the nutritional status of Polish preschoolers.

CONCLUSIONS
e present study provides evidence that the nutritional status of children should be analyzed in the context of their place of residence. us, the di erences between regions and their impact on the health status of their inhabitants should all be taken into account when designing preventive or corrective measures.